CN IX/X Palsy: A Fact Hard to Swallow

We discussed in clinic a case of possible CNIX/X (gossopharyngeal/vagus nerve) palsy presenting with dysphagia and weight loss. Here’s a quick review of the functionalities of these cranial nerves, how to examine for abnormalities, and differential diagnosis.

CNIX is responsible for swallowing, taste and sensation over the posterior 1/3 of the tongue and palate, promoting salivation from parotid, and it forms the afferent limb of the gag reflex (Walker,1990). CNX is important for  swallowing, phonation, and articulation (as it contributes to the movement of the palate, pharynx, larynx, and esophagus), and forms the efferent limb of the gag reflex. CNX also has autonomic functions such as gastric acid secretion, gallbladder emptying and heart rate regulation.

Physical exam in the context of possible CNIX/X palsy should include a full neurological and head&neck examination (Erman, 2009). Assess the patient’s voice including pattern, loudness, and articulation (e.g. the “ee” sound is hard to hold for more than a few  seconds with vocal cord paralysis). The gag reflex, palate elevation, and swallowing should be evaluated.

Differential for CNIX/X dysfuntion involving systematically thinking about different pathology from the cortex to the neuromuscular junction (Erman, 2009).

§      cortex (contribute to CN IX and X): acute stroke, tumor
§      extrapyramidal tracts (contribute to CN IX and X): extrapyramidal movement disorders
§      brainstem (nuclei): amyotrophic lateral sclerosis, syringomyelia, Arnold-Chiari malformation, tumor
§      peripheral nerve (CN IX and X): cerebellopontine angle tumor, skull base osteomyelitis, skull base fracture, glossopharyngeal neuralgia, diptheria
§      neurmuscular junction: myasthenia gravis

-Jenny

Ágoston Kecskés

992868991

January 11, 2012

Blog Entry #7: Changing habits of practice

            In my previous post, I started headlong into a tirade against Bowen et al.’s article[1] on the transformation of internal medicine residency education in the ambulatory setting. In this post, I continue my tirade.

The aforementioned two claims – that internal medicine residents spend less time training in ambulatory medicine than internists do in practice, and that ambulatory medicine differs significantly from inpatient medicine - seem to be the only driving forces motivating this literature review. Yet the authors find that “substantial changes in ambulatory education are needed” and that, as per the authors’ discussion, these changes should not be limited to simply increasing the amount of time residents spend in the ambulatory setting. Many, if not most, of the authors’ recommendations go well beyond (and tangential to) remedying a perceived discrepancy between training and practice in internal medicine. It feels almost as if the authors’ hypothesis was formulated after the data was collected.

The authors at least mention the argument that “residents might benefit from training tracks tailored to their career plans, so that residents bound for careers as hospitalists would focus on hospital-based training.” This argument raises the question of why the authors did not bother looking into the mismatch between total times spent in residency training versus practice settings per individual instead of on a national level. It would seem incumbent on the authors to ensure at the very least that it is not by design that some residents are not receiving ‘adequate’ amounts of exposure to the ambulatory setting. Instead, the authors conclude that “the core of internal medicine training at the residency level should include a more robust exposure to continuity practice regardless of the resident’s future career choice.” This statement neither is intuitive nor flows from the authors’ findings. More saliently still, it stands in isolation of any cost-benefit analysis. As a result, it could be merely an expensive cop-out. As long as the authors do not have to foot the bill, how could more training possibly be a bad idea? Later in the article, the authors curtly mention that “financial pressures may limit available resources, including faculty time or clinical space.”

In contrast to the rest of this study, the authors’ limitations section is a breath of fresh air. The limitations of this study are so substantial, in fact, that it would seem more appropriate to list them before the results than after the discussion. Of note, the authors admit that most of their recommendations are drawn not from their findings but from “discussions with experts and knowledge of learning theories.” It would seem this paper could have been written without findings of any kind.

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[1] Judith L. Bowen et al., “Changing habits of practice,” Journal of General Internal Medicine, http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2005.0248.x/abstract; accessed 9 January 2012.

Ágoston Kecskés

992868991

January 10, 2012

Blog Entry #6: Changing habits of practice

            I found Bowen et al.’s article[1] on the transformation of internal medicine residency education in the ambulatory setting frustrating. Right at the outset, I felt that the authors had bitten off more than they – or anyone, really - could chew.

The authors open with the anecdotal observation that there’s a discrepancy between the total amounts of time that internists spend in the ambulatory setting and that internal medicine residents spend training in said setting. The authors cited data neither about the distribution of internists’ time by setting nor about that of residents’ time. I am not sure I doubt their claim per se but presumably the data is not difficult to acquire. In fact, the data could easily generate enough material to fuel a second publication. It’s conceivable that the data is not easy to acquire owing of the enormous variation in the way different residency training programs are structured across time and space. In fact, this is very likely true. Consequently, the authors’ claim seems more of a sweeping generalization than appropriate motivation for a publication.

The authors also claim that there are significant differences between inpatient and outpatient practices. The authors even go as far as to give examples of such differences despite that, again, the data to support their claims is lacking. At the very least, one would expect the authors to cite a few case examples. As before, one would expect the data to demonstrate quite a bit of variation across time and space, rendering the claim a sweeping generalization.

…to be continued…

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[1] Judith L. Bowen et al., “Changing habits of practice,” Journal of General Internal Medicine, http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2005.0248.x/abstract; accessed 9 January 2012.

Ágoston Kecskés

992868991

January 9, 2012

Blog Entry #5: Teaching exercise

I spent part of the past weekend piecing together an effective teaching exercise for my CEEP selective. Many of my friends and family members are teachers in some capacity or another. I myself have taught high school, undergraduate, and even medical students in various formats. Thus, I generally think of myself as relatively knowledgeable of the challenges involved in assembling a lesson plan. I must say: I continue to underestimate the challenges that teachers face.

            Part of the challenge is uncertainty. There is uncertainty about what the audience knows, what they would want to know, and what they are capable of absorbing in the given 30-minute teaching format – more in terms of interest than intellectual capacity. Furthermore, these are all uncertainties that will be quickly exposed during the 30 minutes of teaching time. There is also uncertainty inherent in the teaching materials, particularly since my topic – smartphones in medical education – is both very recent and ideally should be evidence-based. There just isn’t very much written about smartphones, let alone anything substantial. For the purpose of formulating a research question worth asking, this is fantastic. From the purpose of conveying a valuable message to my audience, it is less than ideal. Then again, the value of the message is in the eye of the beholder. It’s also true that that if I were teaching dusty, well-established material then keeping the seminar interesting would be the challenge.

            To manage the uncertainty I am facing, I will draw on the experience of my friends and family as well as the perspective of my peers. As I skimmed through the medical education literature on theoretical frameworks for clinical teaching, I came across two useful articles from a series entitled “ABC of learning and teaching in medicine.” [1] [2]

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[1] David M. Kaufman, “Applying educational theory in practice,” British Medical Journal, http://www.bmj.com/content/326/7382/213.full; accessed 8 January 2012

[2] John Spencer, “Learning and teaching in the clinical environment,” British Medical Journal, http://www.bmj.com/content/326/7389/591.1; accessed 8 January 2012

Ambulatory Clinics: Learning Through Reflection

Today, our discussion focused on learning in the ambulatory clinics setting and the publications on this topic. Ambulatory clinics constitute a significant component of many Internists’ practice and yet our exposure to the ambulatory settings is often limited. For example, our own clerkship only includes 4 half-days of ambulatory clinics. Although students often enjoy their ambulatory experience, it sometimes feels as if we have just oriented ourselves before we leave again. My interest in learning more through the ambulatory care setting was one of the reasons that drew me to this selective.

What is the benefit of ambulatory care education and how can we optimize it? The importance of this type of experience lies in the fact ambulatory care is quite different in nature from the inpatient experience. Ambulatory practices often involving managing more complex and chronic conditions, through short but longitudinal visits (Bowen et al., 2005). This means that management plans need to be developed quickly but there is expanded opportunity to see the long-term response to treatments.

Publications on teaching in the ambulatory clinic setting emphasize a few strategies for optimizing learning (Bowen et al., 2005; S. Lipsky, 1999).

1. Matching learning and expectations to learner’s level e.g. through sharing learning goals, consistent relationship between learner and teacher.

2. Encourage students to formulate hypothesis and explain rationale to promote active engagement in clinical decision making.

3. Encourage reflection, journaling of ideas, and identifying personal learning issues.

The last point point is perhaps the most fascinating, as with blogging and our daily discussions, reflection has certainly been an active component of this selective. Reflection is considered a valuable part of clinical learning as it targets readings and helps create meaning from experience. For myself, I find that reflection helps put ideas into context, flush out my questions and learning goals, and encourage exploration of interesting topics. I hope to continue daily reflection as a part of my future routine. :)

-Jenny

Lyme Disease: Diagnose Responsibly

Lyme disease was one of the topic of discussion from ambulatory clinic today. Lyme disease is a disease cause by spirochete bacteria of the genus Borrelia (Sabatine, 2011). These pathogens are transmitted by Ixodes ticks, which in turn is usually carried by animal host such as deer and mice. The effects of Lyme disease can be localized (stage 1), disseminated (stage 2), or persistent (stage 3). Its clinical features include a characteristic bullseye lesion called erythema migrans, as well as fatigue, arthralgia, heart block, myopericarditis, cranial neuropathy, and aseptic meningitis.

Lyme disease diagnosis usually involve serology assessment via ELISA, with Western blot confirmation of postive results. ELISA alone can give false positives in the context of other spirocheta infections and conditions such as SLE, RA, and HIV. Treatment typically involves a course of doxycycline (e.g. 100mg PO BID x 10-21d for early disease and 100-200mg PO BID x 2-4 weeks for disease with significant systemic effects).

A large part of our discussion focused on the impact of overdiagnosis and overtreatment of Lyme disease. Questionable diagnosis of lyme disease in some patients can lead to lengthy, costly, and aggressive treatments. Lyme disease lends itself to this phenomenon because of the possibility of false positive in serological testing and the fact its clinical findings are often complex and non-specific. It is important to be cautious in diagnosing Lyme disease since inappropriate treatment, as expected, leads to negative patient outcomes and misuse of healthcare resources (Reid, Schoen, Evans, Rosenberg, & Horwitz, 1998).

Physical Exam Tip from Dr. Ho Ping Kong: if you want to accentuate muscle fasciculations e.g in the context of neuropathy, it helps to tap gently on the muscle belly. 

1. Sabatine MS. Lyme Disease. In: Pocket medicine. 2011 p. 6-21 - 22.

2. Reid MC, Schoen RT, Evans J, Rosenberg JC, Horwitz RI. The consequences of overdiagnosis and overtreatment of Lyme disease: an observational study. [Internet]. Annals of internal medicine 1998 Mar;128(5):354-62.Available from: http://www.ncbi.nlm.nih.gov/pubmed/9490595   

- Jenny

Ágoston Kecskés

992868991

January 6, 2012

Blog Entry #4: MKSAP

Today we discussed the advantages and disadvantages of the Medical Knowledge Self-Assessment Program (MKSAP).[1] Specifically, we reviewed the 1998 version of the MKSAP.

Most of the advantages of the MKSAP are relatively obvious: it is quite comprehensive, it covers all of the major subspecialty areas of internal medicine, and it facilitates independent learning. I was pleasantly surprised to see the inclusion of an annotated bibliography of the key journal articles referenced in the MKSAP text. Such a resource can be invaluable in familiarizing oneself quickly with some of the landmark studies that guide practice in the various internal medicine subspecialties.

The disadvantages of the MKSAP are more subtle. The MKSAP suffers from all of the drawbacks of a multiple choice question format. For example, self-assessors are asked to select the “best” answer from four choices. While simple, this format belies the underlying complexity of the questions. For instance, one cannot choose an answer that is not presented as one of the four choices. In the same way, many of the questions are leading and do not provide self-assessors an opportunity to answer more realistic, open-ended questions. One also cannot choose more than one answer. This is a particularly frustrating limitation in a scenario given that self-assessors may be accustomed to ordering a battery of tests instead of one test at a time and given that self-assessors have also been taught for years to make decisions based on the whole clinical picture versus a single piece of evidence. It is also worth mentioning that the MKSAP can be prohibitively expensive for many trainees. The MKSAP also makes for a cumbersome point-of-care resource.

Happily, some of the disadvantages of the MKSAP could be readily remedied. For example, the drawback of having equal weighting assigned to unequally important questions could be remedied with a simple weighting system. Alternately, the most basic and important questions could be considered separately in the marking scheme to represent a “core” body of knowledge that self-assessors would have to be familiar with to achieve minimum competency. In addition, the MKSAP could “force” learning by not allowing self-assessors to move on after answering questions without confirming the principles underlying both the correct and incorrect answers. This is particularly true of the newer electronic versions of the MKSAP.

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[1] American College of Physicians, “MKSAP 14 Online - American College of Physicians,” Medical Knowledge Self-Assessment Program, http://mksap15.acponline.org/; accessed January 7, 2012